20/09/08

Common sense HIV testing in the UK – almost

The British HIV Association has issued new guildlines for HIV testing . (pdf) They are very nearly extremely sensible. But…

One in five of the people newly diagnosed with HIV in the UK last year were diagnosed with AIDS at the same time. That means they’d probably been walking around with HIV infection for eight or nine years without ever being tested. Thinking they were uninfected, they might have had more unprotected sex than they would have if they knew they had HIV. Certainly, they’ve got a higher chance of dying in the next two years than people who got diagnosed and put on treatment earlier on. So yes, we want to get more people tested sooner.

The thing is that we’ve got a pretty good idea who is most likely to be infected in Britain. Gay men and people who have come to the UK from sub-Saharan Africa. People who inject drugs. The people that all of those people have sex with, plus people who are having unprotected sex with lots of other people, and who are thus getting infected with other sexually transmitted infections. The new testing guidelines very specifically say that all of these people should be offered HIV testing, routinely, every time they come into contact with the health services. They’re listed in sections A and C in the bit of the guidelines that I’ve coped below. (One group not included is people in prison, even though prisons are one of the places where drug users are most likely to be in contact with health services.)

So far so (really very) good. But then the but. The guidelines also recommend testing just about everyone in the areas of the country where more than one in 500 adults is currently known to be infected with HIV (the B section below). This makes very little sense. More importantly, it creates a smokescreen behind which medics can hide. Instead of engaging with their patients, talking to them about their sex lives, assessing their risk behaviour, giving advice about healthy behaviour, they just offer HIV tests to every school teacher in for a hip replacement, every maiden aunt moving to a new job in an area favoured by gay men. You can tell by the wording that some of the people involved in drafting the recommendations were reluctant to impose this unnecessary cost on local health authorities. They should have fought harder to keep it out.

Who should be offered a test?
A. Universal HIV testing is recommended in all of the following settings:
1. GUM or sexual health clinics
2. antenatal services
3. termination of pregnancy services
4. drug dependency programmes
5. healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.

B. An HIV test should be considered in the following settings where diagnosed HIV prevalence
in the local population (PCT/LA) exceeds 2 in 1000 population (see local PCT data†):
1. all men and women registering in general practice
2. all general medical admissions.
The introduction of universal HIV testing in these settings should be thoroughly evaluated for acceptability and feasibility and the resultant data made available to better inform the ongoing implementation of these guidelines.

C. HIV testing should be also routinely offered and recommended to the following patients:
1. all patients presenting for healthcare where HIV, including primary HIV infection, enters the
differential diagnosis (see table of indicator diseases and section on primary HIV infection)
2. all patients diagnosed with a sexually transmitted infection
3. all sexual partners of men and women known to be HIV positive
4. all men who have disclosed sexual contact with other men
5. all female sexual contacts of men who have sex with men
6. all patients reporting a history of injecting drug use
7. all men and women known to be from a country of high HIV prevalence (>1%*)
8. all men and women who report sexual contact abroad or in the UK with individuals from
countries of high HIV prevalence.

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This post was published on 20/09/08 in Money and AIDS.

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5 comments

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  1. Pingback by peripheries » Blog Archive » BHIVA’s guidelines for HIV testing: Who, When & Why?, 20/09/08, 05:30:

    […] at the Wisdom of Whores, thought the guidelines “are very nearly extremely sensible. But…” was making “very little […]

  2. Comment by Roger, 20/09/08, 05:32:

    When there is no guarantee that vulnerability is limited only to a group of people and when treatment can be offered to all, there is no reason to offer testing and treatment on a priority or at-risk basis. To do so would be unethical.

    You know where to read more !

  3. Comment by Alasdair King, 20/09/08, 06:39:

    There are two very good reasons to offer testing on a priority or at-risk basis:

    First, testing people who are unlikely to be affected causes unnecessary distress and pain.

    Second, it means wasting finite money. I want my UK tax money to buy the best health service available, based on clinical need, which means prioritising testing to at-risk groups. Or would you advocate my going for breast cancer screening for my 34-year-old male chest?

  4. Comment by Roger, 22/09/08, 02:04:

    Hi Alasdair,

    Your first opposition is about distress and pain.I would not consider an HIV Test as painful. Distres is another issues very much contextual. It is stressfull because we have made it so. If you are HIV positive you will have to deal with stress. You can put your head in the sand, continue to infect other “inconsciously” but one day it will catch up. Your life expectancy will then be much shorter and you will know what distress is.

    Your second is about cost and how tax payer money should be used. Let’s give GPs and people a minimum of credit and brain but the question here is do we want a US-style NHS or a UK/French style NHS? Then how much money will be saved by not having to treat HIV once the epidemic is over?

    I’d refer you to this below published in last week science. Keep in mind that more than 25 billion has already been invested with a rather poor outcome mostly because dogma and political agendas dictated a response that science and common sense should have been leading (see Elizabeth’s book about this). Time to get ride of the blindfold.

    HIV Testing for Whole Populations

    The Policy Forum “Reassessing HIV prevention” (M. Potts et al., 9 May, p. 749) summarizes current approaches to control of HIV infections. Although these strategies have shown some reduction in prevalence of HIV infections, they are not fully effective. Clearly, new approaches should be considered.

    One approach, first proposed by Montaner et al. (1), would be to test entire populations for HIV infection using polymerase chain reaction (PCR) and then to treat all positives with antiretroviral therapy (HAART). This may be effective, given that patients with the low viral loads achievable by HAART treatment are generally not infectious by sexual routes (2-4) or by maternal transmission to newborns (5, 6).

    This approach would be expensive. We estimate that application to all 17 sub-Saharan countries with HIV prevalence of >5% would cost an average of about $20 billion per year, assuming that screening of populations would take place every 5 years. This is a very high figure, but it is affordable by the major donor nations and would likely have substantial health benefits.

    The approach would face other challenges as well. Extensive training of laboratory and field personnel would be required. Fear of the stigma involved in HIV positivity would have to be addressed by widespread publicity stressing the advantages of HAART for those infected, and for those not yet infected, in the populations screened. This has been effective in Brazil, where 170,000 infected people are already being treated with HAART. This has resulted in stable HIV prevalence (0.6%) since the initiation of widespread screening and treatment in 2000 (7).

    Such a bold plan would require controlled studies to assure its efficacy, but the benefits would likely outweigh the costs.

    Alfred M. Prince

  5. Comment by A, 03/10/08, 04:58:

    Hello All,

    I’ve recently read your book and have you to thank for really opening my eyes to the situation in the world. I’m currently in college and am writing a paper on a topic in regards to AIDS. From all that I read and what I’ve experienced in my personal life, personally rubbing elbows with whores of all sexes :). The idea that many are out there not knowing what their status is and spreading to the unknowing populace is a frightening thought.

    I’ve decided to write my paper on a proposed plan to institute mandatory testing (in the US). I understand this is not a popular option, but it seems that the current programs are just not going far enough, and there are many people, that I have run across in my studies that are not positive that the numbers we have on HIV/AIDS infections in the US are even close to being accurate.

    NOTE: I don’t support quarantine of infected persons. My idea is that by making a generalized form of testing for the entire population, say every year, to keep a driver’s license active, or to get your tax refund or something… just to take the test, that’s all.

    I’d like to hear some thoughts on this topic.

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